Despite evidence to suggest shorter durations of antibiotics are safe in complicated appendicitis in children, this practice has not been widely adopted in the UK. We aimed to determine whether a clinical pathway that tailors antibiotics to clinical condition was safe and effective.
A new post-operative pathway (NewPath) was devised that reduced mandatory intravenous antibiotics for complicated appendicitis (perforated or gangrenous) from 5 to 3 days post-operatively, provided the child was apyrexial for >12 hours and tolerating oral diet. Oral antibiotics were only given if white-blood-cell counts were raised. Data were collected prospectively (NewPath) and compared to 100 cases immediately prior to NewPath introduction. Data are presented as median [IQR]. Comparisons used the Fisher’s exact or Mann Whitney U tests as appropriate. Significance was defined as p<0.05.
164 children completed the NewPath over 11 months. Age and normal appendicectomy rate were similar between groups (NewPath vs. existing care, 9y [6-12] vs.10y [7-13] and 19/164 [12%] vs.15/100 [15%]). Rates of complicated appendicitis were 88/164 [54%] vs. 42/100 [42%], p=0.08. For cases of complicated appendicitis, length of stay was shorter for the NewPath (5 [4-7] vs. 7 [6-8] days, p=0.009) and fewer required oral antibiotics on discharge (35/88 [40%] vs. 26/42 [62%], p=0.01). Readmissions within 28 days (24/88 [27%] vs. 8/42 [19%], p=0.39) and intra-abdominal collections (20/88 [23%] vs. 6/42 [14%], p=0.35) were similar between groups.
Post-operative appendicitis care guided by clinical progress and white-blood-cell count can reduce hospital stay and antibiotic use without increasing complications. Applied nationally, pathways such as this have the potential to save considerable health resource. High rates of intra-abdominal collections and hospital readmission highlight the challenge of complicated appendicitis in children and warrant further study.